Failure to Provide Safe Respiratory Care and Adhere to Infection Control Practices
Penalty
Summary
A resident with a history of cerebral infarction, venous thrombosis, embolism, and a tracheostomy was not provided safe and appropriate respiratory care as required by the comprehensive care plan and professional standards. During observation, a nurse entered the resident's room from the nurse's station without performing hand hygiene, then cleaned the resident's mouth of secretions without donning gloves or washing hands. The resident's tracheostomy corrugated tubing was found on the floor next to the bed and was also zip-tied to the bedside table, contrary to facility policy and infection control standards. The resident was fully dependent on staff for all personal care and unable to communicate due to cognitive impairment. Interviews with the nurse, ADON, DON, and Administrator confirmed that the tubing should not have been on the floor or zip-tied to the bedside table, and that hand hygiene should have been performed prior to resident contact. Facility policies reviewed also required hand hygiene before resident care and specified proper handling of respiratory equipment. The failure to follow these procedures was directly observed and acknowledged by staff, constituting a deficiency in providing safe and sufficient respiratory care.